Aetna AFA Medical and Stop Loss Employee Enrollment/Change Form
Instructions: You must complete this enrollment form in full. If you do not, we will return it to you, and that can delay its processing. You alone are responsible for its accuracy and completeness. If
waiving coverage, please complete sections A and B.
Employer name
Effective date
Date of hire
Member ID number (if available)
New hire
Change of coverage
Employee termination
COBRA for:
Employee
Dependent
Rehire / reinstatement
Add spouse / civil union / domestic partner
Remove spouse / civil union / domestic partner
Length of continuation:
New group enrollment
Add dependent child
Remove dependent child
18
36
Other
Late enrollment
Name change
Cancel coverage
Original qualifying event date
Waiver
Other
Qualifying event
Open enrollment
Reason
Other
A. Employee information
Social Security number
Last name, first name, middle initial
Contact telephone (if we may contact
Work ZIP code
Work email address (if we may correspond
you by telephone)
with you via email)
(
)
-
Home address
Apt. Number City, state
Home ZIP code
Mailing address (if different from home address)
Apt. Number City, state
Mailing ZIP code
Number of hours worked a week
Check one:
Full time
1099
Seasonal
COBRA
Part time
Retired
Temporary
Union
Employee acknowledgement: I understand that it is fraud to file an application for coverage, an enrollment form or claim that contains materially false information knowingly and with intent to
defraud. It is illegal to conceal, for the purpose of misleading, information concerning any material fact. A person who commits fraud or intentionally misrepresents material facts is subject to
civil penalties and may be charged with a crime. If you commit fraud or intentionally misrepresent material facts, your coverage can be cancelled or your rates can be increased back to your
effective date.
I certify that all information and statements on this enrollment form are true and complete to the best of my knowledge. I have authority to make statements on behalf of any dependents listed
on this form. If I become aware of any new information after I have completed this enrollment form but before the effective date that would change any answer on this form or make me report something not
reported on this form, I agree to provide that information to Aetna as soon as possible.
Conditions of enrollment:
I understand and agree that my employer’s application will determine coverage and that there is no coverage unless and until Aetna approves both this enrollment form and the
employer application. I agree that my employer or its agent may send this enrollment form to Aetna. I authorize all my doctors, pharmacies, hospitals and other health care providers (“providers”) to give
Aetna any and all personal health information about me and others listed on this form. This authorization covers all health matters including those involving mental health, substance abuse and HIV / AIDS. I
further authorize Aetna to use such information and to disclose such information to affiliates, providers, payors, other insurers, third party administrators, vendors, consultants and governmental authorities
with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related activities. I have discussed the terms of this authorization with my
spouse and competent adult dependents and I have obtained their consent to those terms. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by law. I
understand that I am entitled to receive a copy of this authorization upon request and that a photocopy is as valid as the original.
Please sign here ONLY if you are enrolling in coverage for yourself and / or dependents.
X Employee signature
Date (Month/Day/Year)
GR-69452 (3-24)
SG AFA IMQ R-POD
1
A
5 Slappey & Sadd, LLC 2025 Benefits Guide |
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